Kegawatdaruratan Otak (Siloam - 14 Mei 2008)

Overseas

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Non-HemorrhagicHemorrhagicSurgical aspect : Bypass – anastomosis STA-MCA Endarterectomy Hemicraniectomy

Surgical aspect : Bypass – anastomosis STA-MCA Endarterectomy Hemicraniectomy

Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Vascular NeurosurgerySTROKE

HemorrhagicSTROKE

Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

HemorrhagicSTROKE

Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

Surgical aspect : Hypertensive Stroke Aneurysm AVMs Cavernous Angioma

Clipping

Coiling

HemorrhagicSTROKE

Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Surgical aspect : Hypertensive stroke Aneurysm AVMs Cavernous Angioma

Pre Evacuation Post Evacuation

HemorrhagicSTROKE

Surgical aspect : Hypertensive Aneurysm AVMs Cavernous Angioma

Surgical aspect : Hypertensive Aneurysm AVMs Cavernous Angioma

Non-HemorrhagicSTROKE

Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

AnastomosisSTA-MCA

Non-HemorrhagicSTROKE

Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

Surgical aspect : Bypass-Anastomosis STA-MCA Endaterectomy Hemicraniectomy

• Definition :An interruption of the blood vessel to any part of the brain.– Hemorrhagic Stroke

• An incident of vascular bleeding into the brain

– Non-Hemorrhagic Stroke / Ischemic Stroke (sudden vascular insufficiency)

• Thrombus (a blood clot formed within a vessel)• Embolus ( a blood clot is carried along in the blood

stream)

Location:50% : Basal Ganglia

- Putamen (Common) -

LenticularNuclei - Internal

Capsule, - Globus

Pallidus15% : Thalamus10% : Cerebellum10-20% : Subs Alba1-6% : Brain Stem

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1. Lesion with mass effect, edema, midline shift (herniation).

Notes:Volume consideration :

• 10-30 cc, moderate volume• < 10 cc, not significant• > 85 cc, difficult to survive

2. High ICP sign because of Obstructive Hydrocephalus.

Pre-VP Shunt Post-VP Shunt

Thalamic Bleeding with 3rd Ventricle Obstruction

Brain dead caused by acute hydrocephalus

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3. Superficial location and disturb important function.

Signs & Symptoms Hemiplegi,

hemiparesis, hemihypesthesi

Cognitive failure Difficulty in speaking Paralyses of cranial

nerves Unconsciousness H/A

• Aneurisma• AVMs• Cavernoma

• Description : An Abnormal collection of blood vessels where in arterial

blood flows directly into draining veins without the normal interposed capillary bed.

No brain parenchym contained within the nidus.

Are hamartomatous lesions of the brain, characterized by elongated feeding arteries that directly communicate with draining veins.

Are masses of abnormal vessels and there is no true capillary bed in the body of the malformation. Neither arteries nor veins only abnormal vessels.

Components: nidus, feeding artery, draining vein.

Size of the AVM nidus Location of the AVMs Number and distribution of the

feeding arteries and venous drainage Amount of flow through the AVMs Hematoma surround the AVMs

Kill her or She will kill your

patient !!!!!!!

Definition:

Vascular anomaly characterized by the presence of sinusoidal-like capillary vessels.

Epidemiology:

• Comprise 5-13% of CNS vascular malformation

• Location: Mainly Supra tentorial, 10-23% are in posterior fossa, mostly in the pons.

Supra Tentorial Lesion

Infra Tentorial Lesion

Male,23 yo. Presenting quadriparesis and paralyze of nerve III,VI,VIII,X.MRI showed Cavernoma in posterior part of the pons.

• Rebleeding : 25% on day 1 15-20% on day 14 50 % within 6 months

• Vasospasm : day 3 – 14• Acute hydrocephalus = 15 – 20 %• Hyponatremia (natriuresis and diuresis)• Cardiac arrhythmia due to hypothalamic ischemia

First Bleeding : Headache3 days later :Severe Headache & Convulsion

Vasospasm : delayed, reversible arterial constriction, arised in 3 days after SAH onset (peak 6-8 days).

Presentation:– Major :

• SAH (most common)• Intracerebral hemorrhage

(20-40 %)• Intraventricular

hemorrhage(13-28%)– Minor :

• Mass effect, Seizure, H/A

Cerebral Aneurysm

Grade CriteriaIndex of

Perioperative Mortality (%)

0 Aneurysm is not ruptured 0 – 5

I Asymptomatic or minimal H/A and slight nuchal rigidity 0 – 5

II Moderate to Severe H/A, Nuchal rigidity, but no neurologic deficit other than cranial nerve palsy

2 – 10

III Somnolence, confusion, medium focal deficit 10 – 15

IV Stupor, hemiparesis medium or severe, possible early decerebrate rigidity, vegetative disturbances

60 – 70

V Deep coma, decerebrate rigidity, moribund appearance 70 - 100

CT grading:

1 = None; 2 = < 1 mm think; 3 = > 1 mm, clot; 4 = ICH, IVH* All Patients w/ VASOSPASM were grade 3 0r 4

Most powerful tool in reducing rebleeding risk : – Surgical Clipping– Endovascular coiling

COILINGCLIPPING

CHARACTERISTICS COILING CLIPPING

Size• Small <10 mm

• W/ Small Neck• W/ Large Neck

• Large (10 – 24 mm)• Giant (≥ 25 mm)

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Locationo ACoAo Distal ACAo MCAo PCoAo Paraclinoid ICAo Basilar Apexo PCAo PICA

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Complexity Atheroma / Calcification Intraluminal Thrombus

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POST OPERATIVE SERVICE

Assistant : Closuring CraniotomyOperator : Having Massage