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

Geriatric Neurologic Emergencies

Alan Lucerna, DOEmergency Department

Kennedy University Hospitals - Stratford


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.

Which of these tests is not part of the stroke evaluation in the

ED?

A. CT with contrastB. AccucheckC. ECGD. Cardiac enzymesE. Coagulation panel

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?

A. Age less than 80B. Platelet < 100, 000C. Glucose of 200D. INR 1.2E. SBP 179

According to the recent published trials on the use of rtPA in patients presenting in the 3-4.5 hour window, age

above 80 is a contraindication.A. TrueB. False


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.

CVA

SDH

Trauma

SAH

Dizziness

Meningitis/EpiduralAbscess

Geriatric Trauma

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

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

“But, Doc, she fell from a standing position. It can’t be

that bad….”

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

Image Source: Kennedy Health Systems

81 year old SAH posterior sylvian fissure S/P fall


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%)

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%

• 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

Spinal Injuries

Photo: Microsoft Office Images #MP900385784 (http://office.microsoft.com/en-us/images/)

• 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

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

Spinal Injuries

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

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

Stroke is a Medical Emergency

Image Source: http://commons.wikimedia.org/

Image Source: http://www.nhs.uk/actfast/Pages/stroke.aspx. Used by permission.

http://www.nhs.uk/actfast/Pages/stroke.aspx

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.

Image Source: http://www.nhs.uk/actfast/Pages/stroke.aspx. Used by permission.

http://www.nhs.uk/actfast/Pages/stroke.aspx

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

Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33:149-154.

Copenhagen Study

• Very old (>85) was found to be associated with severe strokes, as was:

• Being female• Having atrial fibrillation• Pre-existing disability

Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33:149-154.

©Image used by permission.

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://emedicine.medscape.com/article/1159752-overview

†http://www.medscape.org/viewarticle/719320

Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Lancet Neurol 2003;2(1):43-53.

©Image used by permission.

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


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


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


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


QuickTime™ and a decompressor

are needed to see this picture.

Intrinsic to the blood vessels of the brain

Embolus from the heart or extracranial vessel

Decreased perfusion pressure or increase blood viscosity

Image Source: Microsoft Images by Fotolia

Image Source: PhotoDisc Health & Medicine Volume 18 . Used by permission.

Rupture of the vessel in Subarachnoid space

or intracerebral space

Image Source: Microsoft Images by Fotolia

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 providershttp://emedicine.medscape.com/article/1159752-overview

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


Stroke Evaluation


• 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

EMS Evaluation and Transport

• 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 60-400- Obvious asymmetry of one following: facial

smile/grimace, hand grip, or arm strength

EMS Stroke Assessment

• 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

Should all “Stroke” patients be transported to Primary Stroke

Center ?

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.

Single most important piece of historical

information…Image Source: Microsoft Images

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

TIME IS BRAINEvery 60 seconds of ischemia leads to

irreversible damage of 1.9 million neurons.

Neurons LostSynapses

LostMyelinated Fibers Lost

Accelerated Aging

Per Stroke

1.2 billion 8.3 trillion7140 km/4470

miles36 years

Per Hour 120 million 830 billion714 km/447

miles3.6 years

Per Minute

1.9 million 14 billion 12 km/7.5 miles 3.1 weeks

Per Second

32000 230 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):263-266.

Estimated Pace of Neural Circuitry Loss in Typical Large Vessel, Supratentorial Acute Ischemic Stroke

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

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?

Acute Stroke SyndromesMotor 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.

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).

Image Source: http://commons.wikimedia.org

Acute Stroke SyndromesPenetrating Blood VesselsPure motor hemiparesis ( classic Lacunar)Pure sensoryPure sensory-motorHemiparesis, homolateral ataxiaDysarthria/clumsy hand

Vertebro-basilar:Cranial nerve palsyCrossed sensory deficitsDiplopia. Dizziness, N/V, dysarthriaDysphagia, hiccupLimp, gait ataxiaMotor deficit, comaB/L signs suggests basilar artery disease

Internal Carotid:Progressive or stuttering onset of MCA syndrome,Occasionally ACA syndrome as well if inadequateCollateral flow

Image Source: http://commons.wikimedia.org

SAHIPH

IS

0102030405060708090

100

Headache and vomiting in stroke subtypes

Sentinel headache

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

Image courtesy of UpToDate. Used by permission.

Baseline NIH Score Percent of Favorable Outcome

< 60 YO

0-9 42

10-14 18

>20 12

61-68 YO0-9 37

10-14 25

>20 0

69-75 YO0-9 54

10-14 27

>20 0

> 75 YO0-9 36

10-14 15

5-20 6

>20 0Uptodate.com (NIHSS: National Institutes of Health Stroke Scale Adapted from NINDS t-PA Stroke Study Group, Stroke 1997; 28:2119)

• 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

Emergency Room Assessment

Oliveira-Filho J, Koroshetz WJ. www.uptodate.com. Accessed September 20, 2010.

http://www.uptodate.com/

• 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

Stroke Alert Algorithm

• LFT• UDS• Etoh• LP• EEG• UA, Blood Cx• Type and

Screen



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 CandidateFor Fibrinolytic Therapy?

Begin Stroke Pathway…

Probable Acute Ischemic Stroke;Consider Fibrinolytic Therapy

No Hemorrhage

Consult NeurologistOr Neurosurgeon;consider transfer

if not available

Hemorrhage

Review Risks/Benefits with PatientAnd Family…

Candidate

Administer AspirinNot Candidate

Identify Signs ofPossible Stroke

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, familymember or caregiver

• Alert hospital• Check glucose if possible

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)

Any Hemorrhage onCT Scan?

NO Hemorrhage:

Probable Acute Ischemic Stroke;Consider Fibrinolytic Therapy• Check for fibrinolytic exclusions• Repeat neurologic exam: are deficits

rapidlyimproving to normal?

Patient Remains CandidateFor Fibrinolytic Therapy?

Candidate for Fibrinolytic Therapy:NOT Candidate for Fibrinolytic Therapy:

Review Risks/Benefits with Patient and Family: If acceptable – • Give tPa• No anticoagulants or antiplatelet

treatment for 24 hours

Administer Aspirin

Hemorrhage:

Consult NeurologistOr Neurosurgeon;consider transfer

if not available

Hemorrhage ORNo Hemorrhage:

• 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

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

Early Signs of Stroke on CT

Image Source: the Radiology Assistant (www.radiologyassistant.nl) Tomura N, et al. Radiology 1988;40(10):463-467.

Hyperattenuation of large vessel (e.g., “hyperdense MCA sign”)Loss of gray-white matter differentiation in the basal ganglia

http://www.radiologyassistant.nl/

2 hours after symptoms


S/P tPA, 16 hours after initial symptoms


21 hours


Day 5


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 Signs of Stroke on CT

• 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. www.uptodate.com. Accessed 9/20/2010.


• TPA in Acute Ischemic Stroke is Level 1 Care!!! The Decision may no longer be yours!!!

Medical Therapy of StrokeAmerican Heart

Association

• 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

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


• 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


Image courtesy of UpToDate. Used by permission.

• 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


rtPA Expansion To 4.5 Hours

• European Cooperative Acute Stroke Study (ECASS)-3

• 28% given tPA at 3-4.5 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:1. patients. older than 80

yrs old2. Taking anticoagulants with INR

1.73. Baseline NIHSS >25

del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Stroke 2009;40(8):2945-2948.

• 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


• 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


rtPA and Stroke Mimics

Image Source: http://commons.wikimedia.org/wiki/File:Phyllocrania_paradoxa_Morphology.jpg. Photo by Mydriatic. Used by permission.

http://commons.wikimedia.org/wiki/File:Phyllocrania_paradoxa_Morphology.jpg

• 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)

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):1340-1345.

- Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: Frequency, clinical characteristics, and outcome. Stroke 2009;40(4):1522-1525.

- Scott PA, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: Characteristics and outcomes. Ann Emerg Med 2003;42(5):611-618.

Stroke Mimics

• Discontinue TPA• Repeat CT• Repeat CBC, PT,PTT, fibrinogen, D-

dimer• Consider

- FFP- Cryoprecipitate- Platelet infusion

• Stat Neurosurgical consult

ICH During Therapy With TPA

• Oxygenation and Airway control• Fever control• Blood Sugars• Seizure control• Hypertension control• Anti coagulant therapy ?• Rapidly progressing

strokes( Brainstem)- Class 1 evidence AHA

Medical Therapy of Stroke Considerations

• Oxygen and Airway control- Give supplemental oxygen to hypoxic

patients- No clear evidence for oxygen for non-

hypoxic patients- Insufficient data on hyperbaric oxygen

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


• 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 10-20 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


Seizure Control• No prophylactic anticonvulsants

recommended- Treat seizures with Benzodiazopines- Prevent further seizures- Witnessed seizure at stroke onset is

Contraindication to Thrombolytic therapy


• 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 !!!


• Head position: Flat vs 30 degrees- Neurology 2005; 64: 1354-1357- 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):1354.-1357.

• 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




If it’s good for acne….

Hayakawa K, Mishima K, Hazekawa M, et al. Stroke 2008;39(3):951-958.

• 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

Spontaneous ICH



Intraparenchymal bleed


A Few Words on 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

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

Chronic SDH

• 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

Aneurysmal SAH

Age & Aneurysmal SAH

<40 41-50 51-60 61-70 >700

10

20

30

40

50

60

70

80 Mortality Serious ComplicationsGood Recovery

Age

%

Data from: Kulchycki LK, Edlow JA. Emerg Med Clin N Am 2006;24(2):273-298.

Poor outcomes in patients who have aneurysmal SAH are related to advanced age, as the Glasgow Outcome Scale (GOS) ratings show here.

• 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

Aneurysmal SAH

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

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

Dizziness

Norrving B, et al. Acta Neurologica Scandinavica 1995;91(1):43-48.

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

Dizziness

• Central Vertigo Causes:– Etoh– Temporal lobe seizures– Migraine– Head trauma– VBI– Posterior fossa mass

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

Dizziness

• Vertigo Treatment:– Steroids may improve outcome in

patients with vestibular neuritis– Modified Epley Maneuver– Meclizine– Benzo’s– Anti-emetic

Dizziness

Epley Maneuver

CNS Infection

• 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

Factors Affecting Geriatric Immunity

• 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

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

Meningitis

Causative Bacteria Meningitisin Patients Older than 50

S pneumoniae N meningitidis

L monocytogenes Aerobic gram-negative bacilli

• 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

Epidural Abscess

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