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1 : Neurological Emergencies in Elderly Patients Ja- Seong Koo M.D. Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea 65..,, 50%, 90%,., 1). 4 2., 85 3,,,,,,,..,,,

2 . (ischemic penumbra),.,. 1. (cerebravascular disease), ( ). 3 ( ), recombinant tissue plasminogen activator(rt-pa), 80% 2).., Framingham , 2. 3)., 1), 55 10, 70 5%. 4,5). (Table 1),.. 7),,, 2.,,, ,,, 6). ( >220 mmhg) (ischemic core)

3 Ja- Se o ng Ko o. Neurological Emergencies in Elderly Patients Table 1. Common patterns of neurological impairments among patients with acute ischemic stroke 6 ) Left(dominant) hemisphere- major or branch cortical infarction Aphasia Right hemiparesis Right- sided sensory loss Right- sided spatial neglect Right homonymous hemianopia Impaired right conjugate gaze Right(nondominant) hemisphere- major or branch cortical infarction Left hemiparesis Left- sided sensory loss Left- sided spatial neglect Left homonymous hemianopia Impaired left conjugate gaze Deep(subcortical) hemisphere or brain stem Hemiparesis (pure motor stroke) or sensory loss(pure sensory stroke) Dysarthria, including dysarthria- clumsy hand Ataxic- hemiparesis No abnormalities of cognition, language, or vision Brainstem Motor or sensory loss in all 4 limbs Crossed signs (signs on same side of face and other side of body) Dysconjugate gaze Nystagmus Ataxia Dysarthria Dysphagia Cerebellum Ipsilateral limb ataxia Gait ataxia 8),, (diffusion weighted image; DWI). (magnetic resonance image; MRI), 9). MRI (magnetic resonance angiography; MRA),

4 .., (computed tomography; CT) 12 95% 24 10),, (posterior fossa).,, 11). 1, 6). CT CT 6). CT mg/dl, CT 6,12)., ST, QT, T,. 13). 2 ),. (hemorrhagic transformation) (1).,. 220 mmhg 120 mmhg 6),, 185 mmhg, 110 mmhg. 14,15).,

5 Ja- Se o ng Ko o. Neurological Emergencies in Elderly Patients labetalol sodium nitroprusside, nifedipine. (unfractionated heparin) 6).,, (2),,,. 6), (low molecular weight heparin) ), 18-20).. 2 aspirin, ticlopidine, triflusal, clopidogrel, aspirin NINDS(National Institute of Neurological Disorders, and Stroke) 3 mg 300 mg, ,22) rt-pa 24 14), ) ,,,., 6.4% 14), 3..,,, 16),

6 .. (headache), 1 (1-year prevalence) 74 90%,, 50, 71 99%, (Table 2) 1 16% 23). 23).,, 1.,, 25).. (Table 3).,,,, 1~16% 24).. Table 2. Diag nostic a larms in the eva luatio n of headac he dis o rde rs 2 3 ) Headache alarm Differential diagnosis Possible work- up Headache begins after age 50 Temporal arteritis, mass lesion ESR, neuroimaging Very sudden onset of headache Headaches increase in frequency and severity New onset headache in patient with risk factors for HIV, cancer Headache with systemic illness (fever, stiff neck) Papilledema Headache following head trauma SAH or other intracranial hemorrhage, pituitary apoplexy Mass lesion, subdural hematoma, medication overuse Meningitis, brain abscess, metastasis Meningitis, encephalitis, systemic illness Mass lesion, pseudotumor, meningitis Subdural hematoma, epidural hematoma, posttraumatic headache Neuroimaging, lumbar puncture if CT is negative Neuroimaging, drug screen Neuroimaging, lumbar puncture Neuroimaging, lumbar puncture, serology Neuroimaging, lumbar puncture Neuroimaging

7 Ja- Se o ng Ko o. Neurological Emergencies in Elderly Patients Table 3. Diagnos is of new headac hes in the e lde rly by sex 2 5 ) Headache diagnosis Men Women Tension type Trigeminal neuralgia Subarachnoid hemorrhage Temporal arteritis Intracranial neoplasm Cervical spine disorder Cranial postherpetic neuralgia Posttraumatic Diseases of ears, nose, sinuses, teeth, jaws Other 20(30%) 9(14%) 5(8%) 5(8%) 5(8%) 2(3%) 4(6%) 4(6%) 1(1%) 11(17%) 63(50%) 27(21%) 10(8%) 7(6%) 3(2%) 4(3%) 2(2%) 0(0%) 3(2%) 8(6%) Total 66(100%) 127(100%),,,,,,,,,.. 1), CT,,, CT (subarachnoid hemorrhage) (intracerebral hemorrhage).,. 2 ),,. (mass effect), CT..,,,,,

8 .,, 80. CT 2/3, 1/3 27). (vertigo), (light- CT. headedness, giddiness), (disequilibrium),. 65 -,. (cranial arteries),.,,,,,,. 26). (jaw claudication) 26). (vertigo), (nearfaint (superficial temporal dizziness), (psychophysiologic dizziness) (disequilibrium) 4 artery)., 2 27) (Table 4).,,,, 3 23). (vertigo) (erythrocyte sedimentation rate; ESR) ( >50 mm/h), CRP(C-reactive (illusion of motion), protein),. 23).,.,. (, 1. 1) ), (dizziness), 75 (Table

9 Ja- Se o ng Ko o. Neurological Emergencies in Elderly Patients Table 4. Mec hanis m and foc us of diagnostic wo rkup fo r diffe re nt types of dizz iness 2 7 ) Type of dizziness Mechanism Focus of evaluation Vertigo Imbalance in tonic vestibular signals Auditory and vestibular systems Near- faint dizziness Psychophysiologic dizziness Decreased blood flow or inadequate glucose to the entire brain Impaired central integration of sensory signals Cardiovascular system, serum glucose Psychiatric assessment Disequilibrium Loss of sensori- motor control Peripheral nerves, spinal cord, inner ear, vision, central nervous system Table 5. Diffe re ntia l pe riphe ra l from ce ntra l ve rtigo 2 7 ) Nausea, vomiting Imbalance Hearing loss Oscillopsia Neurologic symptoms Compensation Peripheral Severe Mild Common Mild Rare Rapid Central Moderate Severe Rare Severe Common Slow 5).,,,. 27). Dix-Hallpike test, Roll-over test., modified Epley maneuver barbecue maneuver (benign paroxysmal positioning vertigo; BPPV) (canalith repositioning) 27). (vestibular neuronitis) (vestibular neuronitis). (vestibular neurolabyrinthitis),, (visual. fixation) (endolymph) (debris), (otolith),,

10 . (gait ataxia), 27).. 2 8). (proprioceptive system) 2 ) (Nea r- fa int d izz ine s s ).,,. (myelopathy) 29).,, (vestibular system), (visual system) 4 ) (Psyc ho phys io lo g ic d izz ine s s ). (global, cerebral hypoperfusion),,,,, 29). (Table 6).,, 3 ) (Dis e quilibrium), (insidious), 29). Table 6. Co mmon c auses of near- fa int dizz iness 2 9 ) Ortho static hypote ns io n Volume depletion Vasodilators, antihypertensive drugs, anaphylaxis, shock Autonomic dysfunction Card iac d is eas e Cardiomyopathy Aortic stenosis Constrictive pericarditis Arrhythmias, conduction defects Vas ovaga l pres ync o pe Hype rve ntilatio n,, 29). 5 ).., (phenytoin, carbamazepine), aminoglycoside,

11 Ja- Se o ng Ko o. Neurological Emergencies in Elderly Patients 29). 1) Odenheimer GL. Geriatric neurology. Neurol Clin 1998;16(3): ) Mohr JP, Caplan LR, Melski JW, Goldstein RJ, Duncan GW, Kistler JP, Pessin MS, Bleich HL. The Harvard cooperative stroke registry: A prospective registry. Neurology 1978;26: ) Wolf PA, DAsostino RB, Belanger AJ. Kannel WB. Probability of stroke: A risk profile from the Framingham study. Stroke 1991;22: ) Aronow WS, Ahn C, Gutstein H. Risk factor for new atherothrombotic brain infarction in 664 older men and 1,488 older women. Am J Cadiol 1996;77: ) Benjamin EJ, Levy D, Vaziri SM. D'Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort: The Framingham Heart Study. JAMA 1994;271: ) Adams HP Jr, Adams RJ, Brott TG, del Zoppo GJ, Furlan AJ, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ. Guidelines for the early management of patients with ischemic stroke: A scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003;34: ) von Arbin M, Britton M, de Faire U, Helmers C, Miah K, Murray V. Validation of admission criteria to a stroke unit. J Chronic Dis 1980;33: ) Panzer RJ, Feibel JH, Barker WH, Griner PF. Predicting the likelihood of hemorrhage in patients with stroke. Arch Intern Med 1985;145: ) Gonzalez RG, Schaefer PW, Buonanno FS, Schwamm LH, Budzik RF, Rordorf G, Wang B, Sorensen AG, Koroshetz WJ. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology 1999;210: ) Treib J, Grauer MT, Woessner R, Morgenthaler M. Treatment of stroke on an intensive care unit: A novel concept. Intensive Care Med 2000;26: ) Hajat C, Hajat S, Sharma P. Effects of poststroke pyrexia on stroke outcome: A meta-analysis of studies in patients. Stroke 2000;31: ) Bruno A, Biller J, Adams HP Jr, Clarke WR, Woolson RF, Williams LS, Hansen MD. Acute blood glucose level and outcome from ischemic stroke: trial of ORG in Acute Stroke Treatment(TOAST) Investigators. Neurology 1999;52: ) Kocan MJ. Cardiovascular effects of acute stroke. Progr Cardiovasc Nurs 1999;14: ) The National Institute of Neurological Disorders, and Stroke rt-pa Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333: ) Brott T, Lu M, Kothari R, Frankel M, Grotta JC, Broderick J, Kwiatkowski T, Lewandowski C, Haley EC, Marler JR, Tilley BC. Hypertension and its treatment in the NINDS rt-pa Stroke Trial. Stroke 1998;29: ) Hart RG. Atrial fibrillation and stroke prevention. New Engl J Med 2003;349(11):

12 . 17) Kay R, Wong KS, Yu YL, Chan YW, Tsoi TH, Ahuja AT, Chan FL, Fong KY, Law CB, Wong A. Low-molecular-weight heparin for the treatment of acute ischemic stroke. New Engl J Med 1995;333: ) Chamorro A. Heparin in acute ischemic stroke: the case for a new clinical trial. Cerebrovasc Dis. 1999;9(Suppl 3): ) Berge E, Abdelnoor M, Nakstad PH, Sandset PM, on behalf of the HAEST study group. Low molecular-weight heparin versus aspirin in patients with acute ischemic stroke and atrial fibrillation: a double-blind randomised study. Lancet 2000;355: ) Diener HC, Ringelstein EB, von Kummer R, Langohr HD, Bewermeyer H, Landgraf H, Hennerici M, Welzel D, Grave M, Brom J, Weidinger G. Treatment of acute ischemic stroke with the low-molecular-weight heparin certoparin: results of the TOPAS trial: Therapy Of the Patients with Acute Stroke(TOPAS) investigators. Stroke 2001; 32: ) International Stroke Trial Collaborative Group. The International Stroke trial(ist): A randomised trial of aspirin, subcutaneous heparin, both, or neither among 19,435 patients with acute ischaemic storke. Lancet 1997;349: ) CAST(Chinese Acute Stroke Trial) Collaborative Group. CAST: Randomised placebo-controlled trial early aspirin use in 20,000 patients with acute ischemic stroke. Lancet 1997;349: ) Newman LC, Lipton RB. Emergency department evaluation of headache. Neurol Clin. 1998;16(2): ) Silberstein SD, Evaluation and emergency treatment of headache Headache 1992;32: ) Pascula J, Berciano J. Experience in the diagnosis of headaches that start in elderly people. J Neurol Neurosurg Psychiatry 1994;57: ) Machado EB, Michet CJ, Ballard DJ, Hunder GG, Beard CM, Chu CP, O'Fallon WM. Trends in incidence and clinical presentation of temporal arteritis in Olmsted County, Minnesota, Arthritis Rheum 1988;31: ) Baloh RW. Emergency department evaluation of headache. Neurol Clin. 1998;16(2): ) Ohbayashi S, Oda M. Yamamoto M. Urano M, Harada K, Horikoshi H, Orihara H, Kitsuda C. Recovery of the vestibular function after vestibular neuronitis. Acta Otolaryngol(Stockh) 1993; 503: ) Baloh RW. Dizziness, hearing loss, and tinnitus. 1st ed. Philadelphia: F.A. Davis Co, 1998;

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440 / / 439 = Abstract = Diffusion-weighted Imaging in Isolated Vertigo Patients Having Risk Factors for Stroke Hyung Goo Kang, M.D., Yu Sang Yun, M.D., Jin Hee Yi, M.D., In Cheol Park, M.D., Kyeong Ryong Lee,