Management of Ischemic Stroke in Geriatric Patients
Stroke is a major cause of death and disability among the elderly, typically defined as individuals over the age of 65. More than 750,000 Americans experience strokes annually, and 160,000 of these do not survive. Of the survivors, approximately one-third experience another stroke within five years.
Evidence is emerging that the morbidity associated with stroke might be lower. Approximately 70% of strokes are associated with uncontrolled hypertension. Therefore, optimization of medication and formation of stroke teams might improve care and minimize disability. This article describes current evidence-based approaches for the treatment of acute ischemic stroke and secondary prevention in geriatric patients.
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PATHOPHYSIOLOGY OF CEREBROVASCULAR DISEASE
Strokes are typically classified as hemorrhagic or ischemic events, with ischemia accounting for approximately 85% of all strokes. Transient ischemic attacks (TIAs), although referred to as “mini-strokes,” are not strokes but are considered cere-brovascular risk factors. Most ischemic strokes result from atherosclerotic plaque rupture, causing a thrombus or embolism. Nearly 20% of strokes are associated with cardiogenic embolism resulting from atrial fibrillation. Other possible etio-logic mechanisms include arterial dissection, profound anemia, blood hyperviscosity, venous occlusion, and temporal arteritis. Patients with a greater degree of carotid stenosis are more likely to experience ischemic symptoms.
Clots involved in ischemic strokes are of arterial origin and are composed mostly of fibrin. Typically, these clots are formed in response to tissue injury, resulting in the release of adenosine diphosphate (ADP), epinephrine, thrombin, and thromboxane A2, promoting significant platelet aggregation. Platelets adhere to subendothelial matrix proteins (SEMs), activate the glyco-protein Ilb/IIIa complex, and bind fibrinogen. Fibrinogen binds additional platelets, producing an irreversible thrombus. Ischemia may develop as a result of enlargement of an existing thrombus or release of an embolus, thus compromising blood flow of smaller vessels. cialis professional 20 mg