NEUROSURGICAL MANAGEMENT OF
STROKE:PRACTICE TREND IN THE PHILIPPINES
GERARDO D. LEGASPI M.D.
SECTION OF NEUROSURGERY
DEPARTMENT OF NEUROSCIENCES
UNIVERSITY OF THE PHILIPPINES-PHILIPPINE GENERAL HOSPITAL
PHILIPPINE DEMOGRAPHICS
95 M Filipinos
107 Neurosurgeons
60% in Urban Centers
(Manila, Cebu,
97% General Surgeons
2 Ped Neurosurgeon
1 Spine Neurosurgeon
1 Vascular “hybrid” Neurosurgeon
1 Endovascular Neurosurgeon
Davao)
ENDOVASCULAR SERVICE
2 Neurosurgeons (Manila)
8 Interventional Radiologists
6 in Manila
2 in Cebu
Bulk of cases done by Neurosurgeons
2 Neurosurgeons
6 Interventional Radiologists
2 Interventional
Radiologists
“Yesterday, all my troubles seemed so far away”
Lennon and McCartney
Aneurysm
ICH
AVM
Infarct
Clip
Evacuate
Excise
“Pa complete”
STROKE PROFILE
1,200 cases/year
63% Infarct
28% ICH
9% SAH
Overall Mortality 12%
“Infantile” Stroke Unit
Limited MRI/Cathlab use
Mainly Indigent patients
800 cases/year
72% Infarct
21% ICH
7% SAH
Overall Mortality 5.5%
Established Stroke Unit
MRI/Cathlab open 24 hrs
Mainly private patients
2006 PGH Stroke Data ( Diosdado
Stroke Unit)
Infarct
50%
ICH
40%
SAH
10%
Causes of Mortality
Neurologic
86% (Herniation/Brainstem)
Non-neurologic 14%
Macapagal
STROKE TYPES
INTRACEREBRAL HEMATOMA
Spontaneous supratentorial ICH
INFARCTS
Arterial stenosis/occlusion
SUBARACHNOID HEMORRHAGE
Aneurysms/AV Malformations
Intracerebral Hematoma
Affects 10-20 people /100,000 /year
worldwide
Asians (Chinese and Japanese) 30-35%
Americans (African-Americans) 10-15%.
Philippine data
Manila - 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
STICH II
Neutral Results
On going
<48 hours
GCS : Motor 5/Eye opening 2
Purely Lobar 1 cm from the surface
10-100cc
SSP 2006 Recommendation
Patients may benefit with surgery:
 Basal ganglia or thalamic
 GCS > 4
 Supratentorial ICH > 30 cc (Level IV-V, Grade C)
2006
Surgery for pts in coma but not herniated –
• hematoma is located on the BG,cerebellum
• family is willing to accept the consequences
of persistent vegetative state / irreversible
coma
• Goal is reduction of mortality (survival)
Courtesy of Dr. Carlos Chua
INTRACEREBRAL HEMATOMA
1,200 cases/year
800 cases/year
ICH
28%
Operated 21%
ICH
21%
Operated 20%
Overall Mortality 17.5%
Overall Mortality
12.9%
Distinct Critical Events in ICH
(1st 24 hrs)
Unstable clot
Rebleeding
Hematoma enlargement
0
3
Ultra early
Early
6
Thrombin-induced Neurotoxic edema
12
18
24
30
HRS
Morgenstern, 2001
• POOR outcome
• complicated by rebleeding
Timing of Sx Intervention
Kaneko, 1983
• 83% GOOD outcome
Zuccarello, 1999
• 56% GOOD outcome
“Early”
STICH, Mendelow, 2005
• NEUTRAL
7 RCTs on Surgery for
Supratentorial ICH
Author / Yr
McKissock,1961
Juvela, 1989
Auer, 1989
Batjer, 1990
Chen, 1992
Morgenstern, 1998
No of Cases Surgical method
M
S
91
26
89
26
Craniotomy
50
13
63
50
8
64
Endoscopic aspiration
16
15
Zucarrello, 1999
11
9
Courtesy of Dr. Carlos Chua
Craniotomy
Craniotomy
Craniotomy / stereo /
ventricular drainage
Craniotomy
% Poor
Outcome
M
S
66
81
80
96
74
83
50
58
78
63
69
50
Craniotomy
/
64 2000; 31:2511-2516
44
Fernandez,H et al. Stroke
stereotactic aspiration
Benefit of Surgery in Certain Subgroup of ICH Pts
Putaminal Hemorrhage
Study
No
Case
Surgical
technique
Outcome (%)
Kaneko,
1977
38
Putaminal
• Microsurgery
• < 7 hrs
Good = 89
Poor = 11
Kaneko,
1983
100
Putaminal
•Microsurgery
•< 7hrs
Good = 83
Poor = 17
Fujitsu,
1990
24
Rapidly
deteriorating,
putaminal
• Microsurgery
• < 4 days
Good = 70
Poor = 30
Rapidly
Nievas,
59
• Microsurgery
Mortality =
deteriorating,
2005
16.9
keyhole clot
putaminal,
unpublishe
aspiration
> 30cc
d
Patient selection & surgical technique DOES MATTER !
Endoscopic Evacuation
• Selection criteria
Thalamic hemorrhage with IVH due to hypertension
GCS 12 and below
Surgery performed within 24 hours
Excluded are patients who were comatose, on
antiplatelet/anticoagulants,medical conditions
Mariano et al
St. Luke’s Medical Center
Surgical Technique
Frontal Burr hole (ipsilateral or
contralateral)
Rigid endoscopes
Lactated Ringer’s solution as
irrigation
Suction/Irrigation
Clear up frontal horn first, look for
landmarks(foramen of Munro,choroid
plexus, or septum pellucidum)
Hemostasis by washing and cautery
Intraventricular ICP probe inserted
Continuous EVD
CLOT
THALAMIC SUBSTRATE
Preliminary Results of Endoscopy for TH
Good ICP control, EVD removed by day 3 postop
14/15 patients improvement in
level of consciousness, 1 got worse (rebleed),
no mortality
The hospital stay was 30% shorter and
recovery was faster than previously
treated patients (range 1 to 4 weeks)
Only I patient needed a permanent VP shunt