The elderly population has been growing over the last 30 years, specifically those aged 85 years and older, and this growth has been accompanied by an increased incidence of cerebrovascular disease. This older age group has a two- to threefold greater frequency of both ischemic and hemorrhagic stroke than the group composed of those aged 65 to 74 years (14).

In a study of acute stroke in very old people (≥85 years) by Arboix et al. (2), data were collected on 2,000 patients of all ages between 1986 and 1995. The incidence of stroke was 13% in those 85 years or older, 37% in patients aged 75 to 84 years, and 28% in those 65 to 74 years of age. Stroke was more prevalent in women than in men. The main cardiovascular risk factors were hypertension, atrial fibrillation, and diabetes. More recently, a dramatic several-fold increase in anticoagulation-associated hemorrhages has been noted with no concomitant increase of ischemic stroke in the elderly (age 80 or older). The increase was considered largely due to increase in use of warfarin during the 10-year study period (8). As expected, hemorrhagic stroke was less frequently present (14%) than ischemic stroke (86%), but the ratio of hemorrhagic versus ischemic stroke remained similar over the years. The elderly population had the worst outcome, with longer hospitalizations and the greatest in-hospital mortality rate. Altered consciousness, limb weakness, sensory deficit, parietal and temporal lobe involvement, internal capsule involvement, intraventricular hemorrhage, and respiratory and cardiac events were considered predictive factors of in-hospital morbidity and mortality.

Cerebral hemorrhages can involve the subcortical (ganglionic) or lobar structures. These localizations are equally prevalent, but the causes are different. Hemorrhage from a ruptured arteriovenous malformation is uncommon. Although the cumulative risk of rupture increases, most patients who experience hemorrhage are between 10 and 35 years of age. Hemorrhage into a metastasis or anticoagulation-associated hemorrhages should also be considered. Hypertension-associated cerebral hemorrhages, in particular isolated systolic hypertension, and cerebral amyloid angiopathy are common causes of intracerebral hemorrhage.

Long-standing hypertension is probably a common cause of intracerebral hemorrhage in the elderly. Its presentation can be biphasic, at the onset of the hypertension or later when long-standing injury to the penetrating arteries has resulted in formation of fibrinoid degeneration and, possibly, microaneurysms. The predilection sites in the basal ganglia, pons, and cerebellum attest to that.

Cerebral amyloid angiopathy is a common cause of hemorrhage in the oldest-old (26). It is usually diagnosed at autopsies, suggested by magnetic resonance imaging (MRI), or found in surgical specimens and more often in the temporal and occipital lobes (23). In many instances, amyloid deposits involve leptomeningeal or cortical vessels and can completely and continuously involve the blood vessel wall. Severe
angiopathy can cause lobar cerebral hemorrhage from rupture of a cortical or meningeal vessel and dementia, which is noted by family members. Schutz et al. (24) found that the incidence is 30 to 40 per 100,000 patients 70 years of age and older, which would make cerebral amyloid angiopathy responsible for 30% to 50% of cerebral hemorrhage in this age group. Autopsies have also revealed that the prevalence is 2.3% for those between 65 and 74 years, 8% for those aged 75 to 84 years, and 12% for those older than 85 years (10).

Coagulopathy is an important cause of hemorrhage in this age group, particularly because warfarin is commonly initiated to prevent ischemic stroke in conditions such as atrial fibrillation, prosthetic heart valves, and rheumatic mitral stenosis. When stroke occurs, it has a high morbidity and mortality rate (4). To complicate matters even further, the Massachusetts General Hospital group documented a clear link between cerebral amyloid angiopathy and warfarin-associated lobar hemorrhage.

Trauma can also lead to cerebral hemorrhage and is probably the predominant cause in elderly patients. Hemorrhage caused by trauma is often characterized by frontal and temporal lobe contusions or a blood collection located between the dura and the underlying brain. According to the time interval between the trauma and the onset of symptoms, subdural hematoma is divided into acute (<24 hours), subacute (1 to 10 days), and chronic (>10 days). Subdural hematomas are typically located over the convexity and, in some cases, can be bilateral. Acute subdural hematoma remains a common traumatic cerebral hemorrhage in the elderly.

The clinical findings are manifestations of initial tissue destruction and subsequent mass effect. A tendency is seen for progression of the focal neurologic deficits over a few hours.

Patients with intracerebral hemorrhage complain of headaches, vomiting, and a decreased level of consciousness. The headaches are more common with lobar or cerebellar hematomas. Because the location is near to the meningeal surface, meningeal signs may appear.

A decreased level of consciousness is present in large cerebral hematomas causing brainstem shift and when the lesion is located primarily in the posterior fossa compressing the brainstem. Although the decreased level of alertness is considered an adverse prognostic sign, it may simply reflect a larger volume, more tissue shift, or the development of hydrocephalus. Vomiting is also present as a consequence of the increased press or pressure on the vomiting center in the floor of the fourth ventricle. Seizures can be present in cases of a lobar hemorrhage but are rare in putaminal and thalamic hemorrhage. Most often, seizures occur at the time of the bleeding. One recent large study by Bladin et al. (3) found early-onset seizures (within 2 weeks) in 8% and late-onset seizures in 2.6% of patients, with recurrent seizures only in patients with late-onset seizures.

Fever has been significantly associated with intracerebral hemorrhage and with the presence of mass effect, transtentorial herniation, and intraventricular blood on computed tomography (CT) scan. Patients who developed fever were older but also had larger volume hemorrhages.

The physical findings depend on the location of the hemorrhage. Level of consciousness involves arousal and content. Content disturbances can be more prevalent as a premorbid condition in elderly, and diminished attention and lack of integration should not be interpreted as altered state of consciousness. Acute confusional state commonly affects the elderly patient, who also may be susceptible because of underlying dementia. Sleep becomes quickly disturbed, and additional sedative drugs can cause a more profound state. In putaminal hemorrhage, patients present with hemiplegia, homonymous hemianopia, and eye deviation to the side of the hemorrhage. Mild and transient contralateral hemiparesis and a clinical picture similar to subarachnoid hemorrhage characterize a caudate hemorrhage. Hydrocephalus is a common feature because of the early extension of the bleeding to the ventricles. Hemiplegia, hemisensory syndrome, upward gaze paralysis, and small nonreactive pupils are seen in thalamic hemorrhage. Also seen is frequent communication with the ventricular system, and prognosis is related to the size of the hematoma. A poor prognosis is seen in cases of hydrocephalus caused by aqueductal obstruction.

Lobar cerebral hemorrhages are characterized by hemiparesis of upper limb in frontal hematomas, sensory motor deficit and hemianopia in parietal location, fluent aphasia in dominant temporal hematomas, and homonymous hemianopia in occipital hemorrhages. Because of their superficial location, a better prognosis is seen for lobar hemorrhages than for other types of hematomas because they are easily approached surgically.

In cerebellar hemorrhage, patients complain of sudden vertigo, vomiting, headache, and an inability to stand or walk. Ipsilateral limb ataxia, horizontal gaze palsy, and peripheral facial palsy are present. Pontine hemorrhage is typically massive, bilateral, and characterized by quadriplegia, decerebrate posturing, horizontal ophthalmoplegia, pinpoint reactive pupils, respiratory rhythm abnormalities, coma, and hyperthermia. The clinical features are summarized in Table 19-1.

Acute subdural hematomas are usually associated with severe brain damage. Additional contusions not only are found in direct proximity to the subdural hematoma but can be scattered throughout both hemispheres. The mortality rate for acute subdural hematomas in elderly is extremely high. Age older than 65 years and no motor response or eye opening to pain in combination with no verbal response and postoperative intracranial pressure (ICP) greater than 45 mm Hg are poor predictors of outcome. Chronic subdural hematomas are characterized by persistent headaches for several days, followed by decreased consciousness. They can develop after unrecognized trauma, and their clinical picture is similar to subacute processes. Importantly, in the elderly, brain atrophy provokes stretching of cortical veins, making this age group more susceptible even with a seemingly trivial trauma.