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Geriatric Neurologic Emergencies
Alan Lucerna, DOEmergency Department
Kennedy University Hospitals - Stratford

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.

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

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.

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
Image Source: Kennedy Health Systems

Image Source: Kennedy Health Systems

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.

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.

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

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

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

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

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

Stroke Evaluation
http://emedicine.medscape.com/article/1159752-overview

• 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.

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

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

2 hours after symptoms
Image Source: Kennedy Health Systems

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

21 hours
Image Source: Kennedy Health Systems

Day 5
Image Source: Kennedy Health Systems

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
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
TPA For Acute Ischemic Stroke

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
TPA For Acute Ischemic Stroke

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
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
TPA For Acute Ischemic Stroke

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

• 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
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 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
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
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 !!!
Medical Therapy of Stroke

• 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
Medical Therapy of Stroke
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
Medical Therapy of Stroke
Oliveira-Filho J, Koroshetz WJ. www.uptodate.com. Accessed September 20, 2010.

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

Intraparenchymal bleed
Image Source: Kennedy Health Systems

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

Image Source: Kennedy Health Systems

• 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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