Ischemic Stroke in Elderly - Introduction to Geriatrics - Lecture Slides, Slides of Geriatrics

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Outline:

 Etiology  Age related changes to the brain and stroke risk factors  Epidemiology  Outcome  Thrombolysis  Conclusion

The Aging brain:

 Decreased brain weight (0.3-0.5% per year in people > 70)  Enlarged ventricles and thickened choroid plexus  Disruption of local perfusion due to microvasculature changes  Increase in BBB permeability  ?neuronal loss vs neuronal atrophy  ?changes in ion transporters and neurotransmitter production The question remains….how do these changes affect the vulnerability of the brain?

Age related risk factors for

ischemic stroke:

 Female  Atrial fibrillation  Cardiovascular diseases (ischemic heart disease and heart failure)  Carotid stenosis  Hypertension (more important <80 yo)  High blood cholesterol

Stroke outcomes:

 Feb 2010, Circulation published a retrospective study to compare age related differences in patients with ischemic stroke  April 2003 to March 2009 included 502 036 ischemic stroke patients from 1256 hospitals around the United States  33.5% of patients were >80yrs old  Pts >90yo vs pts <50 yo: ○ Incase hospital fatality: 10.3% vs 3% (p <0.001) ○ Discharged to LTC: 42.1% vs 5.3% (p <0.001) ○ Unable to ambulate: 40.1% vs 9.6% (p<0.001)

Criteria for rtPA in acute stroke:

 Onset of symptoms within 3 hours  “Large” neurologic deficit that isn’t improving  No contraindications including:  CT evidence of cerebral hemorrhage or mass effect  Blood pressure >185/  Use of anticoagulants within past 48hrs (increased INR, PTT or low platelets)  Recent stroke, head injury, major bleeding or major surgery  Seizures at onset of stroke  Glucose <3 or >  MI within 3 weeks

However….

 The European Journal of Neurology compared the outcome of the use of rtPA in pts >80yo with those <80yo  July 2001 to May 2007 prospectively assessed 157 pts treated with IV rtPA within 3hrs of stroke  Pts were followed with CT or MRI and NIHSS  Baseline NIHSS score and neuro changes after IV rtPA were not different between elderly and non-elderly at 1 hour, 1 day, 7 days and finally at 90 days

Cont’d….

 Mortality in elderly was 6% vs 10% in non- elderly (not significant)  Severe intracranial hemorrhage was 6% in elderly vs 5.5% in non-elderly (not significant)  The ONLY independent risk factor for worse outcome was the severity NIHSS score prior to rtPA administration  Conclusion: elderly should not be denied rtPA if they fit the criteria for administration and RCT’s are needed for proper evaluation.

Age and Aging cont’d….

 Rate of “poor outcome” (modified Rankin score 4-5 or death) was higher in the elderly (p<0.0001)  Rate of “favourable outcome” (modified Rankin score 0-1) was not significantly different between groups (p=0.37)  Conclusion: Patients >80yo received rtPA benefit from the therapy though they are more likely to have a clinically poor outcome relative to younger patients

Nature reviews neurology Sept

 Data indicates that elderly patients with stroke show marked improvement following rtPA  Studies suggest that the risk of ICH and mortality are not increased when using rtPA in the elderly vs younger pts.  In Conclusion: for more objective conclusions relating to the use of rtPA in elderly patients RCTs including this population are required