NEUROSURGICAL MANAGEMENT OF STROKE:PRACTICE TREND IN THE PHILIPPINES
GERARDO D. LEGASPI M.D.SECTION OF NEUROSURGERY
DEPARTMENT OF NEUROSCIENCESUNIVERSITY OF THE PHILIPPINES-PHILIPPINE GENERAL HOSPITAL
PHILIPPINE DEMOGRAPHICS
95 M Filipinos107 Neurosurgeons
60% in Urban Centers (Manila, Cebu, Davao)
97% General Surgeons2 Ped Neurosurgeon1 Spine Neurosurgeon1 Vascular “hybrid” Neurosurgeon1 Endovascular Neurosurgeon
ENDOVASCULAR SERVICE
2 Neurosurgeons (Manila)
8 Interventional Radiologists6 in Manila2 in Cebu
Bulk of cases done by Neurosurgeons
2 Neurosurgeons6 Interventional Radiologists
2 Interventional Radiologists
“Yesterday, all my troubles seemed so far away”Lennon and McCartney
Aneurysm ClipICH EvacuateAVM ExciseInfarct “Pa complete”
STROKE PROFILE
1,200 cases/year 63% Infarct28% ICH 9% SAH
Overall Mortality 12%“Infantile” Stroke Unit Limited MRI/Cathlab useMainly Indigent patients
800 cases/year72% Infarct21% ICH 7% SAH
Overall Mortality 5.5%Established Stroke UnitMRI/Cathlab open 24 hrsMainly private patients
2006 PGH Stroke Data ( Diosdado Macapagal Stroke Unit)
Infarct 50%ICH 40%SAH 10%
Causes of MortalityNeurologic 86% (Herniation/Brainstem)Non-neurologic 14%
STROKE TYPES
INTRACEREBRAL HEMATOMASpontaneous supratentorial ICH
INFARCTSArterial stenosis/occlusion
SUBARACHNOID HEMORRHAGEAneurysms/AV Malformations
Intracerebral Hematoma
Affects 10-20 people /100,000 /yearworldwide
Asians (Chinese and Japanese) 30-35%Americans (African-Americans) 10-15%.
Philippine dataManila - 30% of stroke admissions (7
teaching hospitals ) Cebu City 25-30% of all stroke admissions ( 6 PCP
training hospitals )
SURGERY FOR SUPRATENTORIAL ICH
STICH I Neutral ResultsSTICH II On going
<48 hours GCS : Motor 5/Eye opening 2Purely Lobar 1 cm from the surface 10-100cc
2006
Patients Patients maymay benefit with surgery: benefit with surgery: Basal ganglia or thalamicBasal ganglia or thalamic GCS > 4GCS > 4 Supratentorial ICH > 30 cc (Level IV-V, Grade C)Supratentorial ICH > 30 cc (Level IV-V, Grade C)
SSP 2006 Recommendation SSP 2006 Recommendation SSP 2006 Recommendation SSP 2006 Recommendation
Surgery for pts in coma but not herniated – Surgery for pts in coma but not herniated – • hematoma is located on the BG,cerebellumhematoma is located on the BG,cerebellum• family is willing to accept the consequencesfamily is willing to accept the consequences of persistent vegetative state / irreversibleof persistent vegetative state / irreversible comacoma• Goal is reduction of mortality (survival)Goal is reduction of mortality (survival)
Courtesy of Dr. Carlos ChuaCourtesy of Dr. Carlos Chua
INTRACEREBRAL HEMATOMA
1,200 cases/year
ICH 28% Operated 21%
Overall Mortality 17.5%
800 cases/year
ICH 21% Operated 20%
Overall Mortality 12.9%
Distinct Critical Events in ICH(1st 24 hrs)
Unstable clotUnstable clot
Hematoma enlargementHematoma enlargement Thrombin-induced Neurotoxic edemaThrombin-induced Neurotoxic edema
Timing of Sx InterventionUltra early Ultra early Morgenstern, 2001• POOR outcome• complicated by rebleeding
Early Early
“Early” “Early”
Kaneko, 1983 • 83% GOOD outcome
Zuccarello, 1999• 56% GOOD outcome STICH, Mendelow, 2005
• NEUTRAL
0 3 6 12 18 24 30 HRS
Rebleeding
Author / Yr No of Cases Surgical method % Poor Outcome
M S M SMcKissock,1961 91 89 Craniotomy 66 80Juvela, 1989 26 26 Craniotomy 81 96Auer, 1989 50 50 Endoscopic aspiration 74 58Batjer, 1990 13 8 Craniotomy 83 78Chen, 1992 63 64 Craniotomy / stereo /
ventricular drainage50 63
Morgenstern, 1998 16 15 Craniotomy 69 50Zucarrello, 1999 11 9 Craniotomy /
stereotactic aspiration64 44
7 RCTs on Surgery for 7 RCTs on Surgery for Supratentorial ICHSupratentorial ICH
7 RCTs on Surgery for 7 RCTs on Surgery for Supratentorial ICHSupratentorial ICH
Fernandez,H et al. Stroke 2000; 31:2511-2516Courtesy of Dr. Carlos ChuaCourtesy of Dr. Carlos Chua
Benefit of Surgery in Certain Subgroup of ICH Pts Benefit of Surgery in Certain Subgroup of ICH Pts Benefit of Surgery in Certain Subgroup of ICH Pts Benefit of Surgery in Certain Subgroup of ICH Pts
Study No Case Surgical technique
Outcome (%)
Kaneko, 1977
38 Putaminal • Microsurgery• < 7 hrs
Good = 89Poor = 11
Kaneko, 1983
100 Putaminal •Microsurgery•< 7hrs
Good = 83 Poor = 17
Fujitsu, 1990
24 Rapidly deterioratin
g,putaminal
• Microsurgery• < 4 days
Good = 70Poor = 30
Nievas, 2005unpublished
59 Rapidly deterioratin
g,putaminal, > 30cc
• Microsurgery keyhole clot aspiration
Mortality = 16.9Patient selection & surgical technique DOES MATTER !Patient selection & surgical technique DOES MATTER !
Putaminal Hemorrhage
Endoscopic Evacuation
• Selection criteriaThalamic hemorrhage with IVH due to hypertension
GCS 12 and belowSurgery performed within 24 hoursExcluded are patients who were comatose, on
antiplatelet/anticoagulants,medical conditions
Mariano et al Mariano et al St. Luke’s Medical CenterSt. Luke’s Medical Center
Surgical TechniqueSurgical TechniqueFrontal Burr hole (ipsilateral or Frontal Burr hole (ipsilateral or contralateral)contralateral)Rigid endoscopes Rigid endoscopes Lactated Ringer’s solution as Lactated Ringer’s solution as irrigationirrigationSuction/IrrigationSuction/IrrigationClear up frontal horn first, look for Clear up frontal horn first, look for landmarks(foramen of Munro,choroid landmarks(foramen of Munro,choroid plexus, or septum pellucidum)plexus, or septum pellucidum)Hemostasis by washing and cauteryHemostasis by washing and cauteryIntraventricular ICP probe insertedIntraventricular ICP probe insertedContinuous EVD Continuous EVD
CLOTCLOT
THALAMIC SUBSTRATETHALAMIC SUBSTRATE
Preliminary Results of Endoscopy for TH
Good ICP control, EVD removed by day 3 postopGood ICP control, EVD removed by day 3 postop14/15 patients improvement in 14/15 patients improvement in level of consciousness, 1 got worse (rebleed),level of consciousness, 1 got worse (rebleed), no mortalityno mortalityThe hospital stay was 30% shorter andThe hospital stay was 30% shorter and recovery was faster than previously recovery was faster than previously treated patients (range 1 to 4 weeks)treated patients (range 1 to 4 weeks)Only I patient needed a permanent VP shuntOnly I patient needed a permanent VP shunt