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Surgery in Elderly 2

Cerebrovascular accident, or stroke, is a common medical emergency among the elderly population. It is the third leading cause of death. Strokes can be ischemic, resulting from blood clots, or hemorrhagic, resulting from bleeding in the brain. Risk factors include older age, hypertension, smoking, obesity, atrial fibrillation, diabetes, and high cholesterol. Strokes cause neurological deficits like weakness or speech problems that appear suddenly. Diagnosis involves CT or MRI scans. Treatment depends on the type of stroke, but may include blood thinners, surgery, and rehabilitation therapy. Preventing strokes is important and involves controlling risk factors and lifestyle changes.

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Zeba Naveed
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33 views41 pages

Surgery in Elderly 2

Cerebrovascular accident, or stroke, is a common medical emergency among the elderly population. It is the third leading cause of death. Strokes can be ischemic, resulting from blood clots, or hemorrhagic, resulting from bleeding in the brain. Risk factors include older age, hypertension, smoking, obesity, atrial fibrillation, diabetes, and high cholesterol. Strokes cause neurological deficits like weakness or speech problems that appear suddenly. Diagnosis involves CT or MRI scans. Treatment depends on the type of stroke, but may include blood thinners, surgery, and rehabilitation therapy. Preventing strokes is important and involves controlling risk factors and lifestyle changes.

Uploaded by

Zeba Naveed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Cerebrovascular Accident in

Elderly
Dr Shailaja V Rao,
Associate Professor,
Department of Geriatrics,
Government Medical College, Aurangabad
Introduction
• CVA/Stroke is a common medical
emergency
• Incidence increases with age
• Third leading cause of death
• About 20% of stroke patients die within a
month
• Half of the patients are left with permanent
disability .
Cerebrovascular accident
• Abrupt onset neurological
disorder of vascular etiology
• It can be :
• Ischemic (85%)
• Hemorrhagic ( 15%)
Anatomy of CNS
Homunculus: the motor or the sensory
distribution along the cerebral cortex of the brain
Brainstem
Cerebral Circulation
The Carotid and Vertebral system
Causes of cerebrovascular accident
Common causes Uncommon causes
Thrombosis Hypercoagulable disorders
Lacunar stroke ( small vessel)
Large vessel thrombosis
Dehydration
Embolic occlusion Venous sinus thrombosis
Artery to artery
Cardioembolic
Paradoxical embolus
Atrial septal aneurysm Vasculitis
Spontaneous echo contrast Non inflammatory vasculopathy
RISK FACTORS
• Old age
• Hypertension
• Smoking
• Obesity
• Atrial fibrillation
• Diabetes
• Carotid stenosis
• Hyperlipidemia
Pathophysiology of acute ischemic stroke
• A cerebral infarct can be seen as a lesion
that comprises :
• Dead brain tissue already undergoing
autolysis
• Ischemic swollen recordable tissue
surrounding dead tissue ( ischemic
penumbra )
• Iniatial swollen lesion can exert mass
effect and midline shift , decompressive
craniectomy is done in such cases
Transient Ischemic Attack
• Sudden onset focal
neurological symptoms lasting
less than 24 hours without any
lesion in imaging

• TIA or minor strokes carry an


overall risk of about 10% for
recurrent stroke in the
following 90 days
Risk Stratification post TIA – The ABCD2
Score
• 1. Age > 60 years – 1 point
• 2. Blood pressure on presentation > 140/90 – 1 point
• 3. Clinical features of the TIA—isolated speech (1 point), unilateral
weakness (2 points)
• 4. Duration—< 10 min – 0 points; 10–59 min – 1 point; ≥ 60 min – 2
points
• 5. History of Diabetes—1 point
• Score ≥ 4 represents an elevated risk for recurrence
Management of TIA
• Position patient with head end flat
• Tablet Aspirin 75 mg OD
• Correct risk factors
• Lower BP gradually
• Carotid TIA with more than 70 percent stenosis should be
immediately referred for surgery
• If stenosis more than 50 percent refer within 2 weeks
Recurrent Ischemic Neurologic Deficit
• Stroke which lasts more than 24 hours and settles within a week
Feature Thrombotic Embolic Hemorrhagic
Time of onset In sleep Anytime During activity
Progression On waking up or over Within seconds Over minutes and hours
hours
TIAs Present Present Absent
Vomitting Absent or occasional Absent or occasional Recurrent
Headache Mild or absent Mild or absent Prominent
Early resolution ( within Variable Possible Unusual
days or minutes )
Meningeal irritation absent Absent Maybe present
Carotid Highly supportive Possible Not seen
Bruit/Feeble/absent
carotid pulse
Irregularly irregular Unusual Highly supportive Not seen
pulse/atrial fibrillation
Clinical features
• Weakness
• Speech disturbance
• Visual deficit
• Visuo-spatial dysfunction
• Ataxia
• Headache
• Seizure
• Coma
Differential diagnosis
Structural stroke mimics Functional stroke mimics
Primary cerebral tumours Todds paresis ( after epileptic seizure )
Metastatic cerebral tumours Hypolycemia
Extradural or subdural hematoma Migraine aura
Demyelination Focal seizures
Peripheral nerve lesions Encephalitis
Cerebral abscess Meniere`s disease or other vascular disorder
Characteristic features of stroke and non
stroke syndromes
Feature Stroke Stroke mimics
Symptom onset Sudden ( minutes ) Often slower onset
Symptom progression Rapidly reaches maximum severity Often gradual onset
Severity of deficit Unequivocal Maybe variable/uncertain
Pattern of deficit Hemispheric pattern Maybe nonspecific with
delirium ,memory loss, balance
disturbance
Loss of conciousness Uncommon More common
Total Anterior Circulation Syndrome
Partial anterior circulation syndrome
Lacunar syndrome
Posterior circulation stroke
INTRACEREBRAL HEMORRHAGE
Changes with Old age
Investigations
• CT scan of brain
• ECG
• Blood biochemistry
• Serum lipid profile
• Fundus examination
• Carotid arterial doppler
• MRI brain with angiography
• 2D echo
Medical Management
• Injection Mannitol
• Antiplatelets
• Statins
• Correct hyperglycemia

• Thrombolysis if patient arrives in Golden period and is an eligible


candidate for same
Surgical Management
• Carotid Endarterectomy
• Carotid stenting
• Carotid embolectomy
and clot retrieval
• Decompressive
Craniectomy
• Ventricular drain
Algorithm for stroke management
STROKE THROMBOLYSIS
Complications of Acute Ischemic Stroke
Care of Bedridden patients
• Active and passive physiotherapy
• Frequent Change of position
• Catheter care
• Bed sore prevention
• Elimination care
• Nutrition.
• Medication
• Emotional support
Bedsores can be prevented
by using airbeds
Stroke Rehabilitation
Cognitive Impairment after Stroke
Course and Mortality
• First week: mortality depends on size of infarct and cardiovascular
status
• Later weeks: lung Infections,UTI, Metabolic Disturbances
References
• Davidson’s Principles and Practice of Medicine.23rd Edition Page 590-
600

• Hazzards Textbook of Geriatrics and Gerontology,8th Edition


Thank You

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