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