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ISCHEMIC

Stroke in the Elderly

Yudha Haryono, dr., Sp., S


Departement Neurology Madical Faculty of
Airlangga University Dr. Soetomo General Hospital
Surabaya

Simposium Emergency for Every Doctor


28 Januari 2017
Introduction :

Approximately 16 Million first-ever


Strokes
+ 5,7 million people /year

Second most common single cause of


death after ischemic heart disease

The largest cause of adult disability and


needing longterm health care
medical burden
3 % total health care
Introduction :

Incidence & Prevalence ~ age


> 55 year

75 89 % Strokes > 65 years

poor outcomes of ischemic stroke in the


elderly patients
AGING RELATED CHANGES IN THE CNS

Brain weight 0,1 % / year between the


age of 20 60 year
More rapid loss
: cerebral cortex & hippocampus
Brain volume : 0,1 - 0,2 % , 30 - 50 years
0,3 - 0,5 %, > 70 years
Neuronal loss, neuronal atrophy
dendritic and perikaryal atrophy
NT & Reseptors
Degeneration of Astrocytic &
Microglial hyperactivity
on CT / MRI : Leukoaraiosis
( patch on periventzicular &
subcortical area : low density )
Leukoaraiosis Risk of Recurrent Stroke

Glutamate Cascade Ca influx


Brain Microvascular (BBB)
capillary surface area
CBF 20 %
Accumulation of Glutamade and
lactate
Electrolyte immbalance
Ischemic Neuronal Death
Macmillan, Neurology Volum e 6, 2010
AGING RELATED RISK FACTOR
Incidence of stroke :
Morbidily & Mortality age

80 year : >
< 80 year : >

AF & CHD > Cardioembolic Ischemic Stroke


1,5 % - 23,5 %

Carotid artery stenosis


Macmillan, Neurology Volum e 6, 2010
CLINICAL MANIFESTATIONS

Acute on chronic : Neuro emergency


Older Patiens : More severe deficits
Recover more slowly
Vascular respons to stress and
injury
Multiple organ dysfunction
Effect of multiple medications
STROKE THROMBOTIC STROKE EMBOLI
STROKE INFARK STROKE INFARK
TROMBOTIK EMBOLI
ICH
SAH IVH
TRETMENT
Stroke : Neuro Emergancy
Acute on chronic proces
Fundamental approaches to Acute
Ischemic Stroke Therapy
Reperfusion
Neuroprotection

Primary and secondary Stroke Therapy :


Antiplatelet (Aspirin,clopidogrel, etc)
Control of Risk Factors
(a.HT, Dyshipidemia / Statin, etc)
Interventional
rtPA : (Intra Arterial rtPA and Intra Venous rtPA)

up to 3 after ischemic stroke

elder patients, old individuals predisposed to


symptomatic ICH & hemorrhagic transformation
microangiophaty (cerebral amyloid angiopathy,
hypertensive microangiopathy) and leukoaraiosis

Higher mortility risk and less favorable outcomes


NEUROPROTECTION

to protect neurons from ischemic reperfusion


injury

to amplify the time window for trombolytic


treatment

> 1000 drugs, only 100 by reached clinical trial


(animal human clinical trial)
ANTIPLATELET DRUGS

Inhibit platelet adhesian and agregation

early mortality : 48 of sympton onset

L.D. Aspirin 22 %, clopidogrel


ANTIHYPERTENSIVE

30 40 % Stroke insidence
39 % Rate of death from Stroke (HYVET)
30 % Risk of Recurent Stroke

Sistolic BP 140 - 150 mmtlg save in older in


Diastolic BP 80 - 90 mmtlg dividual
risk of cerebral
hypoperfusion
(orthostatic)
STATIN

For control of plasma colesterol


Reduce the risk of Ischemic Stroke
Mate analysis : prevention of major vascular event
(22 % RR 65 y, 19 % RR 65 y)
25 % mortality stroke
as an anti inflamatory, anti trombotic, plaque
stabilizing and anti oxidant effects
Neuro protective effect
INTERVENTIONAL

inthe elderly is limited and poor


prognosis